Uterine Prolapse

October 3, 2011

Uterine prolapse or dropped womb is a condition in which the uterus drops downward in the pelvis below its normal position. The uterus may drop slightly and remain above the introitus (vaginal opening, grade 1). It may drop further so that the cervix or lower portion of the uterus reach the region of the introitus (grade 2). In the most severe form, the cervix or even the entire uterus bulges out of the introitus (grade 3). Uterine prolapse is the indication for hysterectomy in 16% of cases in the U.S.

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What is Uterine Prolapse, What is Genital Prolapse

Uterine prolapse or dropped womb is a condition in which the uterus drops downward in the pelvis below its normal position. The uterus may drop slightly and remain above the introitus (vaginal opening, grade 1). It may drop further so that the cervix or lower portion of the uterus reach the region of the introitus (grade 2). In the most severe form, the cervix or even the entire uterus bulges out of the introitus (grade 3). Uterine prolapse is the indication for hysterectomy in 16% of cases in the U.S.

Genital prolapse is a more general term which includes several conditions, which may occur separately or in combination. These include uterine prolapse (dropped womb), vaginal prolapse, cystocele (dropped bladder), rectocele (dropped rectum), and enterocele (herniation of small bowel into the space between the rectum and vagina).

What are the Causes of Uterine and Genital Prolapse

Uterine and genital prolapse may rarely be caused by congenital (inherent) weakness of the pelvic floor (muscles, ligaments, fascias that support the pelvic floor and prevent pelvic organs from dropping down). More commonly, genital prolapse is caused by damage to the pelvic floor during vaginal deliveries (especially those with protracted labor), instrumental deliveries (forceps, vacuum extraction) and the vaginal delivery of large babies. Aging and menopause can weaken the pelvic floor because of diminished estrogen levels. The tissues comprising the pelvic floor are weakened in the absence of sufficient estrogen levels. Increased intra-abdominal pressure on a long term basis can contribute to genital prolapse, for instance, heavy manual labor, heavy lifting, use of a tight abdominal girdle. Chronic coughing and straining at bowel movements because of chronic constipation are also important contributing factors in genital prolapse.

What are the Symptoms of Uterine and Genital Prolapse

Symptoms depend on the genital organs involved in the prolapse as well as the degree of the prolapse. Mild degrees of uterine prolapse, cystocele or rectocele may not cause any discomfort. A more significant uterine prolapse may cause pelvic pain or pressure. It may also interfere with sexual function. Cystocele may cause pelvic discomfort and sexual dysfunction and may involve urinary stress incontinence (loss of urine with stress such as cough). Rectocele can cause rectal pressure and constipation. Prolapse which results in a protrusion of the uterus and/or vagina out of the vaginal introitus may lead to irritation, ulceration and infection. Genital prolapse may have a detrimental effect on sexual intercourse by interfering with penetration and by lack of vaginal tone.

What are the Non-Surgical Treatment Options for Genital Prolapse

Mild degrees of cystocele, rectocele or uterine prolapse may not require any intervention, especially if the patient has no discomfort. Special exercises to strengthen pelvic floor muscles (Kegal), especially when guided by biofeedback, can improve symptoms, urinary stress incontinence, sexual function and pelvic discomfort. In fact, reduction of the size of a cystocele can be documented. Change in lifestyle such as eliminating heavy lifting or use of a tight girdle, treatment and suppression of a chronic cough, treatment of chronic constipation, can halt the progression of genital prolapse.

Estrogen replacement therapy (combined with a progestin) can improve the strength of the pelvic floor ligaments and muscles, bring an improvement in symptoms and increase the effectiveness of Kegal exercises.

Pessaries are special prostheses of different shapes and sizes that are fitted into the vagina and can effectively prevent the prolapse. The pessary must be fitted according to the type and degree of prolapse. Specialized pessaries can also effectively prevent urinary stress incontinence.

What is the Role of Surgery in Genital Prolapse

Surgery is designed to repair and reconstruct the weakened pelvic floor and restore normal function. It is indicated only when the prolapse is causing significant symptoms and when conservative non-surgical measures have failed. Also when conservative measures are not desired by the patient and she is requesting relief by means of surgery. Surgery is rarely indicated for mild degrees of prolapse.

Surgery to correct prolapse requires great expertise and meticulous attention to details. The weakened and stretched ligaments and muscles of the pelvic floor must frequently be reused in the repair process. These ligaments may fail again. It is, therefore, frequently necessary to use more sophisticated suspension techniques for a successful and long lasting outcome. Pretreatment with estrogen, when deficient, may increase the success of surgery. For cystocele, rectocele, enterocele and relaxed introitus (vaginal opening) specific procedures are available that can effectively correct the condition. In all these conditions, as well as in the treatment of urinary stress incontinence, the removal of the non-prolapsed, normal uterus is of no proven benefit.

Minimal uterine prolapse is usually not accompanied by any discomfort and can be monitored without any intervention. When the prolapse is more significant and symptomatic, treatment is necessary. If conservative treatment fails or is not desired surgery is indicated. There are several operations that can lift the dropped uterus to its original position without resorting to hysterectomy. These operations are customized according to the specific anatomical deviation leading to the prolapse, the general physical condition of the patient and the desire to have continued vaginal penetration with sex. The prevailing opinion among gynecologists is that the surgical correction of uterine prolapse is more effective and less likely to fail in the long run if it includes a hysterectomy. However, there are no large prospective studies to validate this opinion. In the elderly woman who does not have vaginal intercourse the prolapse may be corrected by a subtotal closure of the vagina (partial colpocleisis). This procedure is better tolerated than hysterectomy.

In conclusion, mild prolapse can usually be treated with conservative measures. When surgical correction of prolapse is required, it is possible to perform corrective surgery without a hysterectomy. Concerns have been voiced regarding the longevity of such repairs. The informed patient who chooses to preserve her uterus should look for a surgeon who is experienced and willing to perform such procedures.